Physical Examination Demonstration Systems Approach

A. PRELIMINARY Washes hands before starting examination (in front of patient) B. VITAL SIGNS Blood pressure done - 1 arm Systolic BP estimated by palpation of brachial or radial arteries with BP cuff BP done correctly (not over clothing, cuff tight, arm correct relaxed position, etc.) Patient seated with back supported and both feet flat on ground Blood pressure taken with the bell of the stethoscope Heart rate - at least 15 seconds checking radial pulse with fingers, not thumb Respiratory rate - inconspicuously watching chest movement (at least 20-30 seconds) Temperature (done correctly – will beep when done if electronic)

10. C. HEAD Palpates scalp: 11. Palpates thoroughly (temples, including over temporal arteries), parietal – sides above ears, crown, occipital – back, palpate temporomandibular joint as patient opens and closes jaw

Eyes Inspect Visual acuity Extraoccular movements, accommodation Visual fields Pupillary response, swinging flashlight Fundoscopic exam

Inspect, Visual acuity

Inspect, Visual acuity 12. D. EYES Inspects external ocular (eye) structures (lids, conjunctiva, iris cornea, pupils) 13. Gently moves eyelids up and down to obtain better view 14. Checks acuity with Snellen and from proper distance (12-14 inches and any printed material is acceptable) 15. Checks acuity both eyes separately

Extraoccular movements, accommodation 16. Evaluates extraocular movement (big H) 17. Checks convergence and accommodation (follows finger from far to near)

Visual Fields

Visual fields 18.Visual fields - both eyes independently 19. Visual fields - eight cardinal directions for each eye (N,NE, E, SE, S, SW, W NW) 20. Visual fields - simultaneous stimulation (each eye should only be able to see on hand – the one on that side) 21. Visual Fields – Examiners hands or object to view introduced in the plane half-way between patient and examiner

Pupillary response, swinging flashlight

Pupillary response, swinging flashlight 22. Pupillary response to light – direct (same eye the light is directed into) 23. Pupillary response – indirect (eye light is not directed into) 24. Swinging flashlight test (start in one eye, quickly move to other eye, wait then fast back to original eye and wait)

Fundoscopic exam Ophthalmologic Examination: Lights are dimmed Examiner uses R hand R eye to look in R eye Inspects anterior structures ophthalmoscope - R eye (start at + 15-40 to see anterior structures and move toward 0) Inspects optic nerve - R eye (comes in at 15 0 with lens at 0 or moving from the positive towards 0) Traces vessels to all four quadrants - R eye Observes macula - R eye (credit to be given if #28 and look laterally) Examiner uses L hand L eye to look in L eye Inspects anterior structure ophthalmoscope - L eye (start at + 15-40 to see anterior structures and move toward 0) Inspects optic nerve - L eye (comes in at 15 0 with lens at 0 or moving from the positive towards 0) Traces vessels to all four quadrants - L eye Observes macula - L eye (credit to be given if #33 and look laterally)

Fundoscopic exam

Fundoscopic exam Ophthalmologic Examination: Lights are dimmed Examiner uses R hand R eye to look in R eye Inspects anterior structures ophthalmoscope - R eye (start at + 15-40 to see anterior structures and move toward 0) Inspects optic nerve - R eye (comes in at 15 0 with lens at 0 or moving from the positive towards 0) Traces vessels to all four quadrants - R eye Observes macula - R eye (credit to be given if #28 and look laterally) Examiner uses L hand L eye to look in L eye Inspects anterior structure ophthalmoscope - L eye (start at + 15-40 to see anterior structures and move toward 0) Inspects optic nerve - L eye (comes in at 15 0 with lens at 0 or moving from the positive towards 0) Traces vessels to all four quadrants - L eye Observes macula - L eye (credit to be given if #33 and look laterally)

Ears Inspect Palpate Acuity Otoscope

Ears 36. E. EARS: Inspects externally bilaterally (including behind ears) 37. Palpates auricles bilaterally 38. Otoscopic examination bilaterally 39. Otoscopic examination performed without pain 40. Auricles pulled superiorly, posteriorly, and away from patient 41. Auditory acuity tested (eyes closed if finger rub and you can see movement of hands or arm) 42. Auditory acuity tested correctly (each ear independently, etc.)

Nose and Sinuses Nasal Speculum Palpate sinuses

Nose and Sinuses 43. F. NOSE Otoscope used with nasal speculum to inspect nasal vault or may use otoscope ear speculum 44. Nasal speculum examination done without causing pain 45. Palpate frontal sinus for tenderness (medial brow left and right, be sure not too high) 46. Palpate maxillary sinus for tenderness (correct position) 47. Palpate ethmoid sinus (bridge of nose) for tenderness

Mouth Look everywhere Say “ah”

Mouth 48. G. MOUTH Should use light source for inspection 49. Inspect lips, gums, buccal mucosa, teeth 50. Inspect tongue, posterior pharynx 51. Inspect floor of mouth (under tongue) 52. Elevation of palate ("ah") 52. Examination done with minimal discomfort

Neck Inspect Carotids: palpate, auscultate (2) Thyroid: isthmus and both lobes 10 lymph node areas

Carotids

10 Lymph Node Areas

Thyroid

Neck 54.H. NECK Inspects anterior neck for symmetry 55.Carotid arteries palpated 56.Carotid arteries correctly palpated, singly, (lower third of neck), fingers or thumb 57.Auscultation of carotid arteries (lower carotids bilaterally) 58.Auscultation of carotid arteries (upper carotids bilaterally) 59.Thyroid gland palpated: Palpation from behind, chin is slightly extended (can palpate from front) 60.Hands in proper position (below the cricoid cartilage) 61.Palpates the isthmus and has patient swallow 62.Palpates the lobes and has patient swallow 63. I. LYMPH NODES - HEAD AND NECK Periauricular (in front of the ear)64. 65.Posterior auricular (behind the ear) 66.Occipital (base of skull) 67.Tonsillar (angle of jaw) 68.Submaxillary (mid-jaw) 69.Submental (under chin) 70.Posterior cervical (back of neck) 71. Superficial cervical (on top of the sternomastoid muscle) 72. Deep cervical (deep in the sternomastoid muscle) 73. Supraclavicular

Chest Posterior, anterior, lateral Inspection Chest expansion Proper position Start at apices Tactile fremitus Percussion Diaphragmatic movement Costovertebral angle Auscultation

Chest Expansion

Tactile Fremitus

Diaphragmatic Movement

CVA Tenderness

Posterior Chest 84. K. CHEST - Posterior Chest: Inspection: For symmetry 85. Palpation: Bilateral movement chest wall (hands on sides, try to bring thumbs together, moderate pressure) 86. Palpation: For tactile fremitus (attempted) 87. Palpation: Alternates from side to side or may use both hands simultaneously 88. Percussion: Check diaphragmatic movement bilaterally 89. Percussion: Posterior lung fields (attempted) 90. Percussion: Alternates from side to side 91. Percussion: Done correctly bilaterally, symmetrically, good tone 92. Auscultation: Bilaterally (attempted) 93. Auscultation: Done correctly (above scapula, 3 - 4 places, throughout inspiration and expiration) 94. Auscultation: Patient instructed deep slow breaths, mouth open 95. Auscultation: Alternates from side to side 96.Auscultation: At least 3 - 4 areas auscultated posteriorly 97. Arms crossed for tactile eremites, percussion and auscultation 98.Lateral Chest. Percussion laterally can be done as part of anterior or posterior 99.Auscultation laterally can be done as part of anterior or posterior 100.Other: Stethoscope placed examiner's ears correctly 101.Other: Correct order of inspection (palpation or percussion), auscultation 102.Percussion over costovertebral angle

Anterior Chest 73.J. CHEST -- Anterior Chest (lying or sitting or at 30 0) Inspection: For symmetry 74.Palpation: For tactile fremitus (attempted) 75.Palpation: Alternates from side to side or may use both hands simultaneously 76.Percussion: Anterior chest (attempted) 77.Percussion: Alternates from side to side 78.Percussion: Done correctly (bilaterally, symmetrically, good tone) 79.Auscultation: Bilaterally (attempted) 80.Auscultation: Done correctly (above clavicle, 3-4 places, listens throughout inspiration and expiration) 81.Auscultation: Patient instructed slow, deep breath, mouth open 82.Auscultation: Alternates from side to side 83.Auscultation: At least 3-4 areas auscultated on each side

Cardiac Exam Jugular venous pulsation Inspection Palpation Auscultation Special maneuvers

Cardiac Exam Jugular venous pulsation Inspection Palpation Valve areas PMI Left lateral decubitus Auscultation Diaphragm Bell Tricuspid, mitral Special maneuvers Left lateral decubitus, apex, bell Sit up, lean, LLSB, exhale, diaphragm

Jugular Venous Pulsations

Jugular Venous Pulsations

PMI

Auscultation Areas

Auscultation Areas

Special Maneuvers: MS

Special Maneuvers: AR (AI)

CV Exam 103.L. CARDIAC Inspection jugular vein (remember can be done at 0, 15, 30, will likely move table position) 104. Inspection done correctly; right side, head tilted left, patient elevated 105. Inspection, palpation and auscultation for rest of cardiac examination performed at 30 degrees 106.Inspection of all 4 areas 107.Palpation of aortic area (right second intercostal space just lateral to sternum) 108. Palpation of pulmonic area (left second intercostal space just lateral to sternum) 109.Palpation of right ventricular area (left lower sternal border) 110.Palpation of apical area (about fifth intercostal space mid-clavicular line) 111.If apical impulse not palpable, patient in left lateral decubitus 112.Palpation done with fingerpads in all 4 areas 113.Auscultation with Diaphragm Aortic area 114.Auscultation with Diaphragm Pulmonic area 115.Auscultation with Diaphragm Tricuspid area (left lower sternal border) 116.Auscultation with Diaphragm Mitral area (apical area) 117.Auscultation with Diaphragm Sitting, left lower sternal border, patient fully exhaled 118.Auscultation with bell. Tricuspid area 119.Auscultation with bell. Mitral area 120.Auscultation with bell. Mitral area in the left lateral decubitus position 121.Done correctly - Bell applied light pressure, not heavy (remember newer stethoscopes diaphragm lightly OK) 122Other. Stethoscope placed in examiner's ears correctly

Abd Exam Inspection Auscultation Percussion Palpation

Abd Exam Inspection Auscultation Percussion Palpation All 4 quadrants Liver span Palpation Liver Spleen Right lateral ducubitus Kidneys Aorta

Palpation: Liver

Palpation: Spleen

Palpation: Kidneys

Palpation: Aorta

Abd 123. M. ABDOMEN. Inspection with adequate exposure (lower chest to pelvis) 124. Auscultation: Listens at least 10 secs. (one place or can move to several areas, must listen for at least 10 secs) 125. Percussion: L abdomen above below umbilicus 126.Percussion: R abdomen above below umbilicus 127. Percussion: Liver span (measure liver span, may do scratch test) 128. Palpation: Lightly, all 4 quadrants 129.Palpation: Deeply, all 4 quadrants 130. Palpation: Liver (attempts to do) 131. Palpation: Liver (correctly – palpating deepest full inspiration, 1 hand under one hand palpating or 2 palpating) 132. Palpation: Spleen (attempts to do) 133. Palpation: Spleen (correctly - position, breaths, palpating deepest full inspiration, 1 hand under L side, 1 feeling) 134. Palpation: Spleen (if not palpable, R lateral decubitus) 135. Palpation: R kidney (take a deep breath, capture kidney, exhale, slowly release kidney 136. Palpation: L kidney (take a deep breath, capture kidney, exhale, slowly release kidney) 137. Palpation: For abdominal aorta (to feel both the left and right walls of the aorta) 138. Palpation: Inspects patient’s face during palpation (at least 50% of the time) 139. In correct order: Inspection, auscultation, percussion and palpation 140. Abdominal Examination was done at 0.